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Sunday, December 14, 2014

The Details Matter...Even When We Are Tired

I had the pleasure of spending some time recently with the Director of Operations (typically the senior aviation professional in an aviation company) of a very large EMS helicopter company. We were discussing recent crashes. I mentioned that I had read a pilot's report to the NTSB stating that he had felt like his approach was fast and steep (as might occur if one were landing with the wind - "downwind") prior to initiating a "go-around" (when we abort an approach to landing, adding power for lift and speed). During the go-around, the aircraft began an uncommanded yaw that turned into several rotations in the yaw axis, loss of control, and a crash.

The D.O. stated that this has happened more than once. Pilot's preparing to land at 2:00 am don't perform as well as they might at 10:00 am, and this is made apparent by studying HEMS crashes.

All pilots know that they should go through a deliberate set of steps prior to landing. A before-landing-check should be performed and announced, a statement of the planned path in (and out) should be made with an announcement of any hazards observed. If you only have one motor, the forced landing location(s) should be announced so that you and all others on board know where you are going when the engine quits.

Sidebar: If your pilot has not announced a visible hazard, like a tower or wires or a vehicle - she might not see it. You must announce it.

And - very importantly - the pilot should announce his or her opinion of where the wind is coming from and how it might affect the helicopter. Often when we land there is no wind sock on scene. So we must determine the wind direction and velocity through other means. If I state where I think the wind is coming from, and you disagree, now is the time to speak up.

Unfortunately for us, when we are out in the wee hours, we don't perform as well (as human beings) as we do during the day when fresh and rested. It's a proven fact. Read the NTSB reports. Our mood, performance, and judgement are degraded.

And that's why we tend to crash more in the middle of the night. When tired we just do the minimum to get by, to get the aircraft and patient to the destination.

We overlook the details.

For this reason, at night is when established procedures, protocols, checklists and company best-practices must be adhered to. Like performing a high recon, like knowing where the wind is from, Like getting the aircraft slowed down per company policy. Like flying the correct angle.

Note that if I am falling short on any of these items - the only persons who can point this out to me are you two or three crew members flying with me. This means you have to know about how things are supposed to look and feel, and speak up if something is off. I am a damned good pilot. And I haven't crashed.

Yet.

This makes me just like your pilot.

As a human being I am subject to make a mistake, like the guy in Texas did. He initiated a go-around, aborting his approach, because it didn't feel right. And it led to a crash. Another guy did the same exact thing. And got into the yawing spin. That fellow went around about 45 times, yes forty five times, before climbing in desperation, falling off to one side, weather-vaning and flying out of it....

Well pardon the crap in my pants...

So perhaps we should focus on getting it right the first time in - especially at night. Some aircraft are more susceptible to loss of tail-rotor effectiveness than others, but they are all subject to vortex-ring state, and hitting things. In any aircraft, a small decrease in rotor RPM - such as might occur during a large power increase when aborting an approach and starting a climb - will equate to a much greater loss of tail-rotor (or fenestron) RPM and authority. In a BK the ratio is 8 to 1 TR to MR. And when that tail rotor stops being effective we will push more pedal until it either is effective or it stalls.

Note: In the first event referred to here, the pilot reported that he did NOT apply FULL pedal against the yaw/spin. We should be ready to apply full pedal to control the aircraft. This has never happened to me, but experts say full pedal will arrest the yawing motion. Both pilots reported that "the cyclic stopped working." This led the DO to surmise that the aircraft, when spinning rapidly - on the order of 360 degrees per second - gets out of sync/phase with cyclic inputs. If the nose is down, and the pilot inputs aft cyclic, the delay in cyclic effect means that the aircraft has spun to the point that the input is reversed. This is something to consider, and more reason to avoid letting the yaw get away from us. Apply full pedal against yaw as required...

Crews can assist with determining wind direction. Flags in the wind, smoke from stacks, groundspeed versus airspeed comparisons, wind correction headings... All these serve to tell us the wind direction and speed. Of course wind can change near the ground, and we have to be ready for this, all of us.

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About Me

I am a retired army aviator, and flew EMS helicopters from 1999 until 2015. I have flown at many different programs under traditional, community based, and hybrid models. I enjoy interacting with crewmembers as we together learn how to avoid becoming a statistic and the topic of someone else's safety brief. I teach Air Medical Resource Management, and am a member of the National EMS Pilot's Association's board of directors.